Ohio providers contracted with Medicare and Medicaid lines of business, serving members enrolled with UnitedHealthcare Connected for Medicare and Medicaid benefits, will be able to take advantage of single-claim submission. Claims submitted to UnitedHealthcare Connected for dual-enrolled members will process first against Medicare benefits and then will process against UnitedHealthcare Connected Medicaid benefits. Most care providers will not need to submit separate claims.
For claims, billing and payment questions, go to UHCprovider.com.
UnitedHealthcare Community Plan follows the same claims process as UnitedHealthcare.
For a complete description of the process, go to UHCprovider.com/guides > View online version > Chapter 9 Our Claims Process.
HIPAA requires you have a unique NPI. The NPI identifies you in all standard transactions.
If you have not applied for a NPI, contact National Plan and Provider Enumeration System (NPPES). Once you have an identifier, report it to UnitedHealthcare Community Plan. Call Provider Services.
Your clean claims must include your NPI and Federal Tax Identification Number. Also include the Unique Care Provider Identification Number (UPIN) laboratory claims.
We only consider reimbursing claims if you met billing and coverage requirements. Submitting a referral does not guarantee we will pay you. Payment depends on the member’s coverage on the dates of service, medical necessity, plan rules about limitations and exclusions, and UnitedHealthcare Community Plan policies. We don’t reimburse excessive, inappropriate or non-covered charges. To comply with applicable standards, policies and law, we may adjust previous payments for services and audit claims. We may seek reimbursement for overpayments or offset future payments as allowed by law.
Based on OAC Rule: 5101:3-1-60, payment by UnitedHealthcare Community Plan is considered payment in full. Participating and non-participating care providers may not bill a member unless all of the following are met:
Reimbursements depend on the fee schedule and the procedure performed. Refer to your bulletins for correct coding.
The member ID card has both the UnitedHealthcare Community Plan member ID and the state Document Control Number (DCN). UnitedHealthcare Community Plan prefers you bill with the member ID.
UnitedHealthcare Community Plan only processes claims submitted on 1500 and UB-04 claim forms.
Use the 02/12 1500 form for ancillary services, ambulatory surgery centers, urgent care centers and hospital services.
Use the UB-04 form for hospital inpatient and outpatient services, dialysis services, skilled nursing homes inpatient services, long-term care facilities, hospice services and other care providers.
Complete a CMS 1500 or UB-04 form whether you submit an electronic or a paper claim. Clean claims have:
We may require additional information for some services, situations or state requirements.
Submit any services completed by NPs or PAs who are part of a collaborative agreement.
Submit paper claims to:
UnitedHealthcare Community Plan
P.O. Box 8207
Kingston, NY 12402
UnitedHealthcare Community Plan complies with EPSDT state standards based on claims data and chart review. Use the UnitedHealthcare ICD-10-CM Code Lookup Tool to find an ICD-9 or ICD-10 code.
You may submit claims by electronic data interchange (EDI). EDI offers less paperwork, reduced postage, less time spent handling claims and faster turnaround.
If you treat another diagnosis, use that ICD CM code as well.
UnitedHealthcare Community Plan’s companion documents are intended to share information within Implementation Guides (IG) adopted by HIPAA. The companion documents identify the data content requested when it is electronically transmitted. UnitedHealthcare Community Plan uses companion documents to:
The companion document provides general information and specific details pertinent to each transaction. These documents should be shared with your software vendor for any programming and field requirements.
The companion documents are located on UHCprovider.com/edi > Go to companion guides.
Software vendor reports only show the claim left your office and was either accepted or rejected. They don’t confirm the claim status. Acknowledgment reports confirm the information you sent has been received. Review your reports, clearinghouse acknowledgment reports and the status reports to reduce processing delays and timely filing penalties.
To get your reports, make sure your software vendor has connected to our clearinghouse OptumInsight at enshealth.com.
If you are not yet an OptumInsight client, we will tell you how to receive Clearinghouse Acknowledgment Reports.
UnitedHealthcare Community Plan offices can help you with Electronic Remittance Advices (ERAs) and Electronic Funds Transfers (EFTs). To use ERAs, you must enroll through a clearinghouse or entity that uses OptumInsight.
Find more information at UHCprovider.com. Click Menu, then Resource Library to find Electronic Data Interchange menu.
Companion documents for 837 transactions are on UHCprovider.com, Click Menu, then Resource Library to find the EDI section
Visit the National Uniform Claim Committee website to learn how to complete the CMS 1500 form.
Follow these tips for 837 claim formats:
Bill all hospital inpatient, outpatient and ER services using revenue codes and the UB-04 claim form:
Capitation is a payment arrangement for health care providers. If you have a capitation agreement with us, we pay you a set amount for each member assigned to you per period of time. We pay you whether or not that person seeks care. In most instances, the capitated care provider is either a medical group or an Independent Practice Association (IPA). In a few instances, however, the capitated care provider may be an ancillary provider or hospital.
We use the term ‘medical group/IPA’ interchangeably with the term ‘capitated care providers’. Capitation payment arrangements apply to participating physicians, health care providers, facilities and ancillary care providers who are capitated for certain UnitedHealthcare Community Plan products. This applies to all benefit plans for members:
Additionally, capitated care providers may be subject to any or all delegated activities. Capitated care providers should refer to their Delegation Grids within their participation agreements to determine which delegated activities the capitated providers are performing on behalf of UnitedHealthcare Community Plan.
For capitated services, include all services related to an inpatient stay on the UB-04 when a member is admitted to the hospital and they received ER treatment, observation or other outpatient hospital services.
We deny claims submitted with service dates that don’t match the itemization and medical records. This is a billing error denial.
Our benefits contracts are subject to subrogation and coordination of benefits (COB) rules:
UnitedHealthcare Community Plan is the payer of last resort. Other coverage should be billed as the primary carrier. When billing UnitedHealthcare Community Plan, submit the primary payer’s Explanation of Benefits or remittance advice with the claim.
Hospital and clinics must bill for professional services bill on a CMS 1500. The servicing provider’s name is placed in box 31, and the servicing provider’s group NPI number is placed in box 33a.
Hospitals should submit claims to the UnitedHealthcare Connected (MyCare Ohio) claims address as soon as possible after service is rendered, using the standard UB-92 Form or electronically.
To expedite claims payment, identify the following items on your claims:
UnitedHealthcare Community Plan performs coding edit procedures based on the Correct Coding Initiative (CCI) and other nationally recognized sources.
Comprehensive and component code combination edits apply when a code pair(s) appears to be related. These edits can be further broken down to explain the bundling rationale. Some of the most common causes for denials in this category are:
Submit your laboratory claims with the Clinical Laboratory Improvements Amendments (CLIA) number. In box 23 of the CMS 1500 claim form, enter the 10-digit CLIA certification number for laboratory services billed by an entity performing CLIA-covered procedures.
If you bill electronically, report the CLIA number in Loop 2300 or 2400, REF/X4,02. For more information about the CLIA number, contact the CMS CLIA Central Office at 410-786-3531 or go to the cms.gov.
When billing multiple units:
Follow this reporting procedure when submitting obstetrical delivery claims. Otherwise, we will deny the claim:
You must report newborn weight to UnitedHealthcare Community Plan.
To report this data, use the appropriate value code:
If billing electronically, please report birth weight in loop 2300, segment HI, with the qualifier BE and the value code “54” in HI01-2 and the newborn’s weight in grams in HI01-5.
We reference the following codes to identify newborn claims. Therefore, include birth weight on all claims containing these codes:
ICD-10 Procedure Codes:
ICD-10 Diagnosis Codes:
The following codes must have a 5th digit equal to 1 or 2:
You must report the date of a member’s last menstrual period to UnitedHealthcare Community Plan. If billing on paper, report the date of the last menstrual period as follows:
If billing electronically, please report the date of the last menstrual period as follows:
ODM covers medically necessary, non-experimental transplants. UnitedHealthcare Community Plan covers the transplant evaluation and work-ups. Get prior authorization for the transplant evaluation. Gather all required referrals and evaluations to complete the pre-transplant evaluation process once the member is a possible candidate.
Ambulance claims must include the point of origin, destination address, city, state, and ZIP.
Claims must include:
Submit the NDC on all claims with procedure codes for care provider-administered drugs in outpatient clinical settings. The claims must show the NDC that appears on the product. Enter the identifier N4, the 11–digit NDC code, unit/basis of measurement qualified, and metric decimal quantity administered. Include HCPCS/CPT codes.
You can ask about claims through UnitedHealthcare Community Plan Provider Services and the UnitedHealthcare Community Plan Provider Portal. To access the portal, go to UHCprovider.com. Follow the instructions to get a user ID. You will receive your user ID and password within 48 hours.
Provider Services helps resolve claims issues. Have the following information ready before you call:
Allow Provider Services 45 days to solve your concern. Limit phone calls to five issues per call.
You can view your online transactions with Link by signing in to Link on UHCprovider.com with your Optum ID. This portal offers you with online support any time.
If you are not already registered, you may do so on the website.
Link lets you move quickly between applications. This helps you:
You can even customize the screen to put these common tasks just one click away.
Find Link training on UHCprovider.com.
To resolve claim issues, contact Provider Services, use Link or resubmit the claim by mail.
Mail paper claims and adjustment requests to:
UnitedHealthcare Community Plan
P.O. Box 5240
Kingston, NY 12402-5240
Allow up to 30 days for UnitedHealthcare Community Plan to receive payment for initial claims and adjustment requests.
Submit a screen shot from your accounting software that shows when you submitted the claim. The screen shot must show the correct:
Timely filing issues may occur if members give the wrong insurance information when you treat them. This results in receiving:
All of the above must include documentation the claim is for the correct member and the correct date of service. A submission report alone is not considered proof of timely filing for electronic claims. They must be accompanied by an acceptance report.
The date on the other carrier’s payment correspondence starts the timely filing period for submission to UnitedHealthcare Community Plan.
To be timely, you must receive the claim within the timely filing period from the date on the other carrier’s correspondence. If we receive the claim after the timely filing period, it will not meet the criteria.
If a claim is rejected, and corrections are not received within 90 days from date of service or close of business from the primary carrier, the claim is considered late billed. It will be denied timely filing.
Timely filing limits can vary based on state requirements and contracts. If you don’t know your timely filing limit, refer to your Provider Agreement.
You may not bill MyCare members. Do not balance bill Medicaid members if:
You may balance bill the member for non-covered services if the member provides written consent prior to getting the service. If you have questions, please contact your provider advocate.
If you don’t know who your provider advocate is, call Provider Services.
UnitedHealthcare Community Plan is, by law, the payer of last resort for eligible members. Therefore, you must bill and obtain an explanation of benefits (EOB) from any other insurance or health care coverage resource before billing UnitedHealthcare Community Plan, as required by contract. Refer to your Agreement for third-party claim submission deadlines. Once you bill the other carrier and receive an EOB, the claim may then be submitted to UnitedHealthcare Community Plan. Please attach a copy of the EOB to the submitted claim. The EOB must be complete to understand the paid amount or denial reason.